The project aims to study a defined population of 32,000 inhabitants from the Municipality of Dorado. There is a Primary care facility in the area that is used as a model family practice site for a Residency Program; and also serves a clinical site for educational and research activities of the Department of Family Medicine and Community HealTh. The University Hospital Dr. Ramon Ruiz Arnau is the tertiary referral center for Dorado and 10 other municipalities in the health region. This project will assess clinical outcomes at the community level. Health problems of high prevalence, such as Diabetes Mellitus, Arterial Hypertension, Congestive Heart Failure, and HIV disease and its relationship with functional health status of the patient will be studied. Data gathering efforts will provide invaluable information about demographical characteristics, outcomes, continuity of care, and utilization of health services. This will also facilitate the flow of patient information for performing mortality, morbidity, and epidemiological research. In addition, it will facilitate the assessment of continuity of care and tracking of the patient progress through different levels of care (ambulatory, hospital, and home care).